Nokea
Which activity should the client who underwent a stapedectomy avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
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The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client's condition when which observation is noted on assessment?
- A. Decreased swelling in the lower extremity
- B. Strong dorsalis pedis pulses felt bilaterally
- C. Increased erythema in the lower extremity
- D. White blood cell (WBC) count 14,000/mm3
Correct Answer: A
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Observing a decrease in swelling is evidence of improvement. Circulation is not involved with cellulitis, so pedal pulses are unaffected. Increased erythema indicates worsening. A WBC of 14,000/mm3 is elevated, indicating infection.
The nurse is most accurate in stating that the cause of Meniere's disease is unknown but that the symptoms are related to which disorder?
- A. A non-suppurative inflammation
- B. A disturbance in the balance of inner ear fluid
- C. An infection in the middle ear
- D. An autoimmune response in the cochlea
Correct Answer: B
Rationale: Meniere's symptoms stem from inner ear fluid imbalance.
The nurse is caring for a male client diagnosed with folliculitis barbae. Which information should the nurse teach to prevent a reoccurrence?
- A. Tell the client to not shave the face.
- B. Instruct the client to rub on astringent aftershave lotion.
- C. Recommend the client apply hot packs for 20 minutes before shaving.
- D. Teach the client to use an antibacterial soap on the face.
Correct Answer: D
Rationale: Antibacterial soap reduces bacterial load, preventing folliculitis barbae. Not shaving is impractical, astringents irritate, and hot packs are less effective.
The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
- A. The lesion is asymmetrical and has irregular borders.
- B. The lesion has a waxy appearance with pearlike borders.
- C. The lesion has a thickened and scaly appearance.
- D. The lesion appeared as a thickened area after an injury.
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.
The female client admitted for an unrelated diagnosis asks the nurse to check her back because 'it itches all the time in that one spot.' When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?
- A. Notify the HCP to check the lesion on rounds.
- B. Measure the lesion and note the color.
- C. Apply lotion to the lesion.
- D. Instruct the client to make sure the HCP checks the lesion.
Correct Answer: B
Rationale: Measuring and documenting the lesion provides baseline data for HCP evaluation. Notification, lotion, or client instruction are secondary.